WAIVER OF RELOCATION ASSISTANCE s. 32.197, Wisconsin Statutes
Submit for approval to: DEPARTMENT OF COMMERCE, DIVISION OF COMMUNITY DEVELOPMENT, RELOCATION UNIT, P.O. BOX 7970, MADISON, WI 53707
An owner-occupant of a property to be acquired may waive relocation assistance under Wisconsin Law. Please review “Waiver Conditions” on reverse side. The waiver must be executed voluntarily, knowledgeably, and all conditions listed on this form must be met. A waiver may not be used for tenant-occupants of property to be acquired. An owner may not waive relocation benefits for anyone else. The waiver relates to items specified above and does not affect an owner-occupant’ rights under other provisions of the law. s The information you provide may be used by other government agency programs {Privacy Law, s. 15.04(1)(m)}. PLEASE PRINT OR TYPE
TODAY’ DATE S PREPARED BY PHONE NUMBER
ACQUIRING AGENCY NAME
PROJECT NAME
NAME OF OWNER-OCCUPANT
HOME PHONE NUMBER
ADDRESS OF PROPERTY
WORK PHONE NUMBER
RELOCATION PAYMENTS WAIVED
MOVE EXPENSE REPLACEMENT HOUSING (includes incidental and increased interest cost) REPLACEMENT BUSINESS/FARM (includes incidental and increased interest) BUSINESS REESTABLISHMENT BUSINESS PAYMENT-IN-LIEU (in lieu of moving and reestablishment payments) RELOCATION SERVICES Yes Yes Yes Yes Yes Yes No No No No No No PAYMENT LIMITS: Actual & Reasonable Cost UP TO $25,000.00 UP TO $50,000.00 UP TO $10,000.00 UP TO $20,000.00 N/A
WAIVER STATEMENT
I have received the pamphlets entitled “ Wisconsin Relocation Rights” and “ The Rights of Landowners under Wisconsin Eminent Domain Law” which were explained to me and which I understood. In addition to being informed and knowledgeable about the relocation payments and services being waived, I know that I will not be required to sell my property unless I voluntarily agree to do so, nor will there be any public actions which might cause me to sell. Also, I voluntarily waive my rights to the above payments as indicated. This waiver expires on ___________________________ unless by this date the agency enters into a written agreement to purchase my property. Other Terms:
SIGNATURE(S) OF OWNER(S) OWNER'S ADDRESS For Commerce Use Only: DATE REVIEWED DATE OWNER APPROVED BY CITY STATE
DATE SIGNED ZIP CODE
APPROVED DATE
CONTACTED
WAIVER CONDITIONS
1. 2. The property has not been identified for acquisition as part of a public project. The property is not located within a proposed or previously identified area where it is reasonable to conclude that acquisition by the agency may occur in the foreseeable future. The property owner-occupant is given the pamphlets, prepared by the Department, entitled “Wisconsin Relocation Rights” and “The Rights of Landowners under Wisconsin Eminent Domain Law”, before execution of the waiver. The property owner-occupant knows the estimated dollar benefits and the kinds of services being waived, before execution of the waiver. The waiver is approved by the Department before initiation of negotiations to acquire the property.
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NOTE TO PROPERTY OWNER: If you have any misgivings about this waiver, you should consider seeking legal advice before signing.